"The Coptic Christians in Egypt and the Ethiopian Orthodox
Christians —two of the oldest surviving forms of Christianity—
retain many of the features of early Christianity, including male
circumcision. Circumcision is not prescribed in other forms of
Christianity.…Some Christian churches in South Africa oppose the
practice, viewing it as a pagan ritual, while others, including the
Nomiya church in Kenya, require circumcision for membership and
participants in focus group discussions in Zambia and Malawi
mentioned similar beliefs that Christians should practice
circumcision since Jesus was circumcised and the Bible teaches the
practice." Male Circumcision: context, criteria and culture
(Part 1), Joint United Nations
Programme on HIV/AIDS, February 26, 2007.

"The decision that Christians need not practice circumcision is
recorded in Acts 15; there was never, however, a prohibition of
circumcision, and it is practiced by Coptic Christians." "circumcision", The Columbia Encyclopedia, Sixth
Edition, 2001-05.

According to the World Health
Organization (WHO), global estimates suggest that 30% of males
are circumcised, of whom 68% are Muslim. The prevalence of
circumcision varies mostly with religious affiliation, and
sometimes culture. Most circumcisions are performed during
adolescence for cultural or religious reasons; in some countries
they are more commonly performed during infancy.

There is controversy
regarding circumcision. Advocates of circumcision argue, for
example, that it provides important health advantages which
outweigh the risks, has no substantial effects on sexual function,
and has a low complication rate when carried out by an experienced
physician. Opponents of circumcision argue, for example, that it
adversely affects normal sexual pleasure and performance, is
justified by medical myths, and is effectively comparable to
female genital cutting.

The American Medical
Association stated in 1999: "Virtually all current policy
statements from specialty societies and medical organizations do
not recommend routine neonatal circumcision, and support the
provision of accurate and unbiased information to parents to inform
their choice."

The World Health Organization (WHO; 2007), the Joint United Nations
Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease
Control and Prevention (CDC; 2008) state that evidence
indicates male circumcision significantly reduces the risk of
HIV acquisition by men during penile-vaginal
sex, but also state that circumcision only provides minimal
protection and should not replace other interventions to prevent
transmission of HIV.

History

Origins

It has been variously proposed that circumcision began as a
religious sacrifice, as a rite of passage marking a boy's entrance
into adulthood, as a form of sympathetic magic to ensure virility, as a
means of suppressing sexual pleasure or to increase a man's
attractiveness to women, or as an aid to hygiene where regular bathing
was impractical, among other possibilities. Immerman et
al. suggest that circumcision causes lowered sexual arousal of
pubescent males, and hypothesize that this was a competitive
advantage to tribes practicing circumcision, leading to its spread
regardless of whether the people understood this.It is possible
that circumcision arose independently in different cultures for
different reasons.

The oldest documentary evidence for circumcision comes from
ancient Egypt. Circumcision was
common, although not universal, among ancient Semitic peoples. In the aftermath of the conquests
of Alexander the Great, however,
Greek dislike of circumcision (they regarded a man as truly "naked"
only if his prepuce was retracted) led to a decline in its
incidence among many peoples that had previously practiced
it.

Circumcision has ancient roots among several ethnic groups in
sub-equatorial Africa, and is still performed on adolescent boys to
symbolize their transition to warrior status or adulthood.

Non-religious circumcision in the English-speaking world

Infant
circumcision was taken up in the United States, Australia and the
English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom.There are several hypotheses to explain why
infant circumcision was accepted in the United States about the
year 1900. The germ theory of
disease elicited an image of the human body as a conveyance for
many dangerous germs, making the public "germ phobic" and
suspicious of dirt and bodily secretions. The penis became "dirty"
by association with its function, and from this premise
circumcision was seen as preventative medicine to be practiced
universally. In the view of many practitioners at the time,
circumcision was a method of treating and preventing masturbation.
Aggleton wrote that John Harvey
Kellogg viewed male circumcision in this way, and further
"advocated an unashamedly punitive approach." Circumcision was also
said to protect against syphilis, phimosis,
paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis). Gollaher states that physicians
advocating circumcision in the late nineteenth century expected
public scepticism, and refined their arguments to overcome
it.

Although it is difficult to determine historical circumcision
rates, one estimate of infant circumcision rates in the United
States holds that 32% of newborn American boys were being
circumcised in 1933. Laumann et al. reported that the
prevalence of circumcision among US-born males was approximately
70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971
respectively. Xu et al. reported that the prevalence of
circumcision among US-born males was 91% for males born in the
1970s and 84% for those born in the 1980s. Between 1981 and 1999,
National Hospital Discharge Survey data from the National Center for Health
Statistics demonstrated that the infant circumcision rate
remained relatively stable within the 60% range, with a minimum of
60.7% in 1988 and a maximum of 67.8% in 1995. A 1987 study found
that the most prominent reasons US parents choose circumcision were
"concerns about the attitudes of peers and their sons' self concept
in the future," rather than medical concerns. However, a later
study speculated that an increased recognition of the potential
benefits of neonatal circumcision may have been responsible for the
observed increase in the US rate between 1988 and 2000. A report by
the Agency
for Healthcare Research and Quality placed the 2005 national
circumcision rate at 56%.

In 1949, the United Kingdom's newly-formed National Health Service removed
infant circumcision from its list of covered services, and
circumcision has since been an out-of-pocket cost to parents. As a
result, prevalence in the UK is age-graded, with 12% of those aged
16–19 years circumcised and 20% of those aged 40–44 years, and the
proportion of newborns circumcised in England and Wales has fallen
to less than one percent.

The circumcision rate has declined sharply in Australia since the
1970s, leading to an age-graded fall in prevalence, with a 2000-01
survey finding 32% of those aged 16–19 years circumcised, 50% for
20–29 years and 64% for those aged 30–39 years.

In some cultures, males must be circumcised shortly after birth,
during childhood, or around puberty as part of a rite of passage.
Circumcision is commonly practised in the Jewish and Islamic
faiths.

Jewish law states that circumcision is a
mitzva aseh("positive
commandment" to perform an act) and is obligatory for Jewish-born
males and for non-circumcised Jewish male converts.It is only postponed or abrogated in the case of threat
to the life or health of the child.It is
usually performed by amohelon the
eighth day after birth in a ceremony called aBrit milah(or Bris milah,
colloquially simply bris), which means "Covenant of
circumcision" in Hebrew.It is considered of
such religious importance that the body of an uncircumcised Jewish
male will sometimes be circumcised before burial.

In Islam, circumcision is mentioned in some
hadith(it is referred as Khitan), but not in the Qur'an.
Some Fiqh scholars state that
circumcision is recommended (Sunnah); others that it is obligatory. Some have
quoted the hadith to argue that the requirement of
circumcision is based on the covenant with Abraham. While endorsing circumcision for males,
Islamic scholars note that it is not a requirement for converting
to Islam.

Illustrated account of the
circumcision ceremony of Sultan Ahmed III's three sons.

Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some
other African churches. Some Christian churches in South Africa
oppose circumcision, viewing it as a pagan ritual, while others,
including the Nomiya church in Kenya, require circumcision for
membership. Some Christian churches celebrate the Circumcision of Christ. The vast
majority of Christians do not practise circumcision as a religious
requirement.

Circumcision in South Korea is largely the result of American
cultural and military influence following the Korean War. In West Africa infant circumcision may have
had tribal significance as a rite of passage or otherwise in the
past; today in some non-Muslim Nigerian societies it
is medicalised and is simply a cultural norm.Circumcision is part
of initiation rites in some African,
Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan
traders from Sulawesi in the
Indonesian Archipelago. Circumcision ceremonies among
certain Australian aboriginal societies are noted for their painful
nature: subincision is practised amongst
some aboriginal peoples in the Western Desert.In the Pacific, ritual
circumcision is nearly universal in the Melanesian islands of
Fiji and Vanuatu;
participation in the traditional land diving on Pentecost
Island is reserved for those who have been
circumcised.

Circumcision is also commonly practiced in
the Polynesian islands of Samoa, Tonga, Niue, and
Tikopia, where the
custom is recorded as a pre-Christian/colonial practice. In
Samoa it is accompanied by a celebration.

Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a
removal of "feminine" aspects of the male, turning boys into fully
masculine males. Among the Urhobo of southern Nigeria it is
symbolic of a boy entering into manhood. The ritual expression,
Omo te Oshare ("the boy is now man"), constitutes a rite
of passage from one age set to another. For
Nilotic peoples, such as the Kalenjin and Maasai,
circumcision is a rite of passage observed collectively by a number
of boys every few years, and boys circumcised at the same time are
taken to be members of a single age set.

Prevalence

Estimates of the proportion of males that are circumcised worldwide
vary from one-sixth to a third. The WHO has estimated that
664,500,000 males aged 15 and over are circumcised (30% global
prevalence), with almost 70% of these being Muslim. Circumcision is most
prevalent in the Muslim world, parts of
South East Asia, Africa, the United
States, The
Philippines, Israel, and South
Korea. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and
Oceania. Prevalence is near-universal in the
Middle East and Central Asia. The WHO states that "there is
generally little non-religious circumcision in Asia, with the
exceptions of the Republic of Korea and the Philippines". The WHO
presents a map of estimated prevalence in which the level is
generally low ( 20%) across Europe, and Klavs et al report
findings that "support the notion that the prevalence is low in
Europe". In Latin America, prevalence is universally low.
Estimates
for individual countries include Spain, Colombia and Denmark less than 2%, Finland and Brazil 7%, Taiwan 9%, Thailand 13% and Australia 58.7%.

The WHO estimates prevalence in the United States and Canada at 75%
and 30%, respectively. Prevalence in Africa varies from less than
20% in some southern African countries to near universal in North
and West Africa.

Modern circumcision procedures

With all these devices the same basic procedure is followed. First,
the amount of foreskin to be removed is estimated. The foreskin is
then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The
inner lining of the foreskin (preputial epithelium) is then bluntly
separated from its attachment to the glans. The device is then
placed (this sometimes requires a dorsal slit) and remains there
until blood flow has stopped. Finally, the foreskin is amputated.
Sometimes, the frenulum
band may need to be broken or crushed and cut from the corona near
the urethra to ensure that the glans can be freely and completely
exposed.

With the Plastibell, once the glans is freed the Plastibell is
placed over the glans, and the foreskin is placed over the
Plastibell. A ligature is then tied firmly
around the foreskin and tightened into a groove in the Plastibell
to achieve hemostasis. Foreskin distal to the ligature is excised
and the handle is snapped off the Plastibell device. The Plastibell
falls from the penis after the wound has healed, typically in four
to six days.

With a Gomco clamp, a section of skin is dorsally crushed with
a hemostat and then slit with scissors. The
foreskin is drawn over the bell shaped portion of the clamp and
inserted through a hole in the base of the clamp. The clamp is
tightened, "crushing the foreskin between the bell and the base
plate." The crushed blood vessels provide hemostasis. The flared
bottom of the bell fits tightly against the hole of the base plate,
so the foreskin may be cut away with a scalpel from above the base
plate.

With a Mogen clamp, the foreskin is pulled dorsally with a
straight hemostat, and lifted. The Mogen clamp is then slid between
the glans and hemostat, following the angle of the corona to "avoid
removing excess skin ventrally and to obtain a superior cosmetic
result" to Gomco or Plastibell circumcisions. The clamp is locked,
and a scalpel is used to cut the skin from the flat (upper) side of
the clamp.

Adult circumcisions are often performed without clamps and require
4 to 6 weeks of abstinence from masturbation or intercourse after the operation
to allow the wound to heal. In some African countries, male
circumcision is often performed by non-medical personnel under
unsterile conditions. After hospital circumcision, the foreskin may
be used in biomedical research, consumer skin-care products, skin
grafts, or β-interferon-based drugs. In
parts of Africa, the foreskin may be dipped in brandy and eaten by
the patient, eaten by the circumciser, or fed to animals. According
to Jewish law, after a Brit milah, the foreskin should be
buried.

Ethical, psychological, and legal considerations

Ethical issues

Ethical questions have been raised over removing healthy,
functioning genital tissue from a minor. Opponents of circumcision
state that infant circumcision infringes upon individual autonomy
and represents a human rights
violation. Rennie et al. note that using circumcision
as a way of preventing HIV in high prevalence, low-income countries
in sub-Saharan Africa, is
controversial, but argue that "it would be unethical to not
seriously consider one of the most promising [...] new approaches
to HIV-prevention in the 25-year history of the epidemic".

Consent

A protest against routine infant
circumcision.

Views differ on whether limits should be placed on caregivers
having a child circumcised.

Some medical associations take the position that the parents should
determine what is in the best interest of the infant or child, but
the Royal
Australasian College of Physicians (RACP) and the British Medical Association
(BMA) observe that controversy exists on this issue.The BMA state
that in general, "the parents should determine how best to promote
their children’s interests, and it is for society to decide what
limits should be imposed on parental choices." They state that
because the parents' interests and the child's interests sometimes
differ, there are "limits on parents' rights to choose and parents
are not entitled to demand medical procedures contrary to their
child's best interests." They state that competent children may
decide for themselves. UNAIDS states that
"[m]ale circumcision is a voluntary surgical procedure and
healthcare providers must ensure that men and young boys are given
all the necessary information toenable them to make free and
informed choices either for or against getting circumcised."

Some argue that the medical problems that have their risk reduced
by circumcision are already rare, can be avoided, and, if they
occur, can usually be treated in less invasive ways than
circumcision. Somerville states
that the removal of healthy genital tissue from a minor should not
be subject to parental discretion and that physicians who perform
the procedure are not acting in accordance with their ethical
duties to the patient. Denniston states that circumcision is
harmful and asserts that in the absence of the individual's
consent, non-therapeutic child circumcision violates several
ethical principles that govern medicine.

Others believe neonatal circumcision is permissible, if parents
should so choose. Viens argues that, in a cultural or religious
context, circumcision is of significant enough importance that
parental consent is sufficient and that there is "an absence of
sufficient evidence or persuasive argumentation" to support
changing the present policy. Benatar and Benatar argue that
circumcision can be beneficial to a male before he would be able to
otherwise provide consent, that "it is far from obvious that
circumcision reduces sexual pleasure," and that "it is far from
clear that non-circumcision leaves open a future person’s options
in every regard."

Acknowledgment of pain

Williams (2003) argued that human attitudes toward the pain that
animals (including humans) experience may not be based on speciesism, developing an analogy between
attitudes toward the pain pigs endure while having their tails
docked, and "our culture's
indifference to the pain that male human infants experience while
being circumcised."

Psychological and emotional consequences

The British Medical Association (2006) states that "it is now
widely accepted, including by the BMA, that this surgical procedure
has medical and psychological risks." Milos and Macris (1992) argue that
circumcision encodes the perinatal brain with violence and
negatively affects infant-maternal bonding and trust. Goldman
(1999) discussed the possible trauma of circumcision on children
and parents, anxieties over the circumcised state, a tendency to
repeat the trauma, and suggested a need on the part of circumcised
doctors to find medical justifications for the procedure.
Furthermore, there are reports of males attempting to undo the
effects of circumcision through the practice of foreskin restoration.Moses et
al.' (1998) state, however, that "scientific evidence is
lacking" for psychological and emotional harm, citing a
longitudinal study which did not find a difference in developmental
and behavioural indices. A literature review by Gerharz and
Haarmann (2000) reached a similar conclusion.Boyle et al.
(2002) state that circumcision may result in psychological harm,
including post-traumatic stress disorder (PTSD), citing a study reporting high rates of PTSD
among Filipino boys after either ritual or medical circumcision.
Hirji et al. (2005) state that "Reports of [...]
psychological trauma are not borne out in studies but remain as an
anecdotal cause for concern."

Legal issues

In 2001, Sweden passed a law allowing only persons certified by the
National Board of Health to circumcise infants, requiring a medical
doctor or an anesthesia nurse to accompany the circumciser and for
anaesthetic to be applied beforehand. Jews and Muslims in Sweden
objected to the law, and in 2001, the World Jewish Congress stated that it
was "the first legal restriction on Jewish religious practice in
Europe since the Nazi era." In 2005, the Swedish National Board of
Health and Welfare reviewed the law and recommended that it be
maintained. In 2006, the U.S. State Department's report on Sweden
stated that most Jewish mohels had been
certified under the law and 3000 Muslim and 40–50 Jewish boys were
circumcised eachyear.

In 2006, a Finnish court found that a parent's actions in having
her 4-year-old son circumcised was illegal. However, no punishment
was assigned by the court, and in 2008 the Finnish Supreme Court
ruled that the mother's actions did not constitute a criminal
offense and that circumcision of a child for religious reasons,
when performed properly, is not a crime. In 2008, the Finnish
government was reported to be considering a new law to legalize
ritual circumcision if the practitioner is a doctor, "according to
the parents' wishes, and with the child's consent", as
reported.

By 2007, the Australian states of Victoria, New South Wales,
Western Australia and Tasmania had stopped the practice of
non-therapeutic male circumcision in all public hospitals.

Medical aspects

Medical
cost-benefit analyses of circumcision have varied. Some found a
small net benefit of circumcision, some found a small net
decrement, and one found that the benefits and risks balanced each
other out and suggested that the decision could "most reasonably be
made on nonmedical factors."

Pain and pain relief

According to the American
Academy of Pediatrics' 1999 Circumcision Policy Statement,
“There is considerable evidence that newborns who are circumcised
without analgesia experience pain and psychologic stress.” It
therefore recommended using pain relief for circumcision. One of
the supporting studies, Taddio 1997, found a correlation between
circumcision and intensity of pain response during vaccination
months later. While acknowledging that there may be "other factors"
besides circumcision to account for different levels of pain
response, they stated that they did not find evidence of such. They
concluded "pretreatment and postoperative
management of neonatal circumcision pain is recommended based on
these results." Other medical associations also cite evidence that
circumcision without anesthetic is painful.

Stang, 1998, found 45% of physicians responding to a survey who
circumcise used anaesthesia – most commonly a dorsal penile nerve
block – for infant circumcisions. The obstetricians in the sample
used anaesthesia less often (25%) than the family practitioners
(56%) or pediatricians (71%). Howard et al. (1998)
surveyed US medical doctor residency programs and directors, and
found that 26% of the programs that taught the circumcision
procedure "failed to provide instruction in anesthesia/analgesia
for the procedure" and recommended that "residency training in
neonatal circumcision should include instruction in pain relief
techniques". A 2006 follow-up study revealed that the percentage of
programs that taught circumcision and also taught administration of
topical or local anesthetic had increased to 97%. However, the
authors of the follow-up study also noted that only 84% of these
programs used anesthetic "frequently or always" when the procedure
was conducted.

Glass, 1999, stated that Jewish ritual circumcision is so quick
that "most mohelim do not routinely use any anaesthesia as
they feel there is probably no need in the neonate." Glass
continued, "However, there is no Talmudic objection and should the
parents wish for local anaesthetic cream to be applied there is no
reason why this cannot be done." Glass also stated that for older
children and adults, a penile block is used.

Lander et al. demonstrated that babies circumcised without
anesthesia showed behavioral and physiological signs of pain and
distress. Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of
pain control have revealed that while both are safe, the dorsal
nerve block controls pain more effectively than topical treatments,
but neither method eliminates pain completely. Razmus et
al. reported that newborns circumcised with the dorsal block
and the ring block in combination with the concentrated oral
sucrose had the lowest pain scores. Ng et al. found that
EMLA cream, in addition to local anaesthetic, effectively reduces
the sharp pain induced by needle puncture.

Sexual effects

The sexual effects of circumcision are the subject of much debate.
The American Academy of Pediatrics (1999) stated "A survey of adult
males using self-report suggests more varied sexual practice and
less sexual dysfunction in circumcised adult men. There are
anecdotal reports that penile sensation and sexual satisfaction are
decreased for circumcised males." They continued, "Masters and Johnson noted no difference
in exteroceptive and light tactile discrimination on the ventral or
dorsal surfaces of the glans penis between circumcised and
uncircumcised men." Conversely a 2002 review by Boyle et
al. stated that "the genitally intact male has thousands of
fine touch receptors and other highly erogenous nerve endings—many
of which are lost to circumcision, with an inevitable reduction in
sexual sensation experienced by circumcised males." They concluded,
"Evidence has also started to accumulate that male circumcision may
result in lifelong physical, sexual, and sometimes psychological
harm as well." In January 2007, The American Academy of Family
Physicians (AAFP) stated "The effect of circumcision on penile
sensation or sexual satisfaction is unknown. Because the epithelium
of a circumcised glans becomes cornified, and because some feel
nerve over-stimulation leads to desensitization, many believe that
the glans of a circumcised penis is less sensitive. [...] No valid
evidence to date, however, supports the notion that being
circumcised affects sexual sensation or satisfaction." Payne et
al. reported that direct measurement of penile sensation
during sexual arousal failed to
support the hypothesised sensory differences associated with
circumcision status.In a 2007 study, Sorrells et al.,
using monofilament touch-test mapping, found that the foreskin
contains the most sensitive parts of the penis, noting that these
parts are lost to circumcision. They also found that "the glans of
the circumcised penis is less sensitive to fine-touch than the
glans of the uncircumcised penis." In a 2008 study, Krieger et
al. stated that "Adult male circumcision was not associated
with sexual dysfunction. Circumcised men reported increased penile
sensitivity and enhanced ease of reaching orgasm."

Reports detailing the effect of circumcision on erectile dysfunction have been mixed.
Studies have shown that circumcision can result in a statistically
significant increase, or decrease, in erectile dysfunction among
circumcised men, while other studies have shown little to no
effect.

Complications

Complication rates ranging from 0.06% to 55% have been cited,
though a 1993 survey of circumcision
complications by Williams and Kapilla put the rate at 2-10%.

According to the American
Medical Association (AMA), blood loss and infection are the most common complications, but
most bleeding is minor and can be stopped by applying pressure. A
survey of circumcision complications by Kaplan in 1983 revealed
that the rate of bleeding complications was between 0.1% and 35%.
A 1999
study of 48 boys who had complications from traditional male
circumcision in Nigeria found that
haemorrhage occurred in 52% of the boys,
infection in 21% and one child had his penis
amputated.

A penis that has been circumcised.

A penis that has not been circumcised.

One study
looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth
complications occurred at a rate of 0.2% in the circumcised babies
and at a rate of 0.01% in the uncircumcised babies. The
authors judged that this was a conservative estimate because it did
not capture the very rare but serious delayed complications
associated with circumcisions (eg, necrotizing fasciitis, cellulitis) and the less serious but more common
complications such as the circumcision
scar or a less than ideal cosmetic result. They also stated
that the risks of circumcision "do not seem to be mitigated by the
hands of more experienced physicians".

Meatal stenosis (a narrowing of the
urethral opening) may be a longer-term complication of
circumcision. It is thought that because the foreskin no longer
protects the meatus, ammonia formed from urine in
wet diapers irritates and inflames the
exposed urethral opening. Meatal stenosis can lead to discomfort
with urination, incontinence,
bleeding after urination and urinary tract infections.

Circumcisions may remove too much or too little skin. If
insufficient skin is removed, the child may still develop phimosis in later life. Van Howe states that "when
operating on the infantile penis, the surgeon cannot adequately
judge the appropriate amount of tissue to remove because the penis
will change considerably as the child ages, such that a small
difference at the time of surgery may translate into a large
difference in the adult circumcised penis. To date (1997), there
have been no published studies showing the ability of a circumciser
to predict the later appearance of the penis."

Cathcart et al. report that 0.5% of boys required a
procedure to revise the circumcision.

Other complications include concealed penis, urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence. Kaplan stated “Virtually all of these
complications are preventable with only a modicum of care" and
"most such complications occur at the hands of inexperienced
operators who are neither urologists nor surgeons.”

Another complication of infant circumcision is skin bridge formation, whereby a remaining part
of the foreskin fuses to other parts of the penis (often the
glans) upon healing. This can result in pain
during erections and minor bleeding can occur if the shaft skin is
forcibly retracted. Van Howe advises that to prevent adhesions
forming after circumcision, parents should be instructed to retract
and clean any skin covering the glans.

Although deaths have been reported, the
American Academy
of Family Physicians states that death is rare, and cites an
estimated death rate of 1 infant in 500,000 from circumcision.
Gairdner's 1949 study reported that an average of 16 children per
year out of about 90,000 died following circumcision in the UK. He
found that most deaths had occurred suddenly under anaesthesia and
could not be explained further, but hemorrhage and infection had
also proven fatal. Deaths attributed to phimosis and circumcision
were grouped together, but Gairdner argued that such deaths were
probably due to the circumcision operation. The penis is thought to
be lost in 1 in 1,000,000 circumcisions.

Sexually transmitted diseases

Human immunodeficiency virus

Over forty observational studies have been conducted to investigate
the relationship between circumcision and HIV infection. Reviews of
these studies have reached differing conclusions about whether
circumcision could be used as a prevention method against HIV.

Experimental evidence was needed to establish a causal relationship
between lack of circumcision and HIV, so three randomized controlled trials
were commissioned as a means to reduce the effect of any confounding factors. Trials took place in
South Africa, Kenya and Uganda. All three trials were stopped early by
their monitoring boards on ethical grounds, because those in the
circumcised group had a lower rate of HIV contraction than the
control group. The results showed that circumcision reduced
vaginal-to-penile transmission of HIV by 60%, 53%, and 51%,
respectively. A meta-analysis of the African randomised controlled
trials found that the risk in circumcised males was 0.44 times that
in uncircumcised males, and that 72 circumcisions would need to be
performed to prevent one HIV infection. The authors also stated
that using circumcision as a means to reduce HIV infection would,
on a national level, require consistently safe sexual practices to
maintain the protective benefit.

As a result of these findings, the WHO and the
Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an
efficacious intervention for HIV prevention but should be carried
out by well trained medical professionals and under conditions of
informed consent. Both the WHO and CDC indicate that
circumcision may not reduce HIV transmission from men to women, and
that data is lacking for the transmission rate of men who engage in
anal sex with a female partner. The joint WHO/UNAIDS recommendation
also notes that circumcision only provides partial protection from
HIV and should never replace known methods of HIV prevention.

Circumcision has been judged to be a cost-effective method to
reduce the spread of HIV in a population, though not necessarily
more cost-effective than condoms. Some have challenged the validity
of the African randomized controlled trials, prompting a number of
researchers to question the effectiveness of circumcision as an HIV
prevention strategy.

In addition to the studies which provided information about
female-to-male transmission, some studies have addressed other
transmission routes. A randomised controlled trial in Uganda found
that male circumcision did not reduce male to female transmission
of HIV. The authors could not rule out the possibility of higher
risk of transmission from men who did not wait for the wound to
fully heal before engaging in intercourse. A meta-analysis of data
from fifteen observational studies of men who have sex with men found
"insufficient evidence that male circumcision protects against HIV
infection or other STIs."

Human papilloma virus

Meta-analyses by Van Howe and Bosch et al. of
observational studies reached differing conclusions as to whether
circumcision reduces infection with human papillomavirus (HPV). A recent
prospective trial in Uganda randomized 3393 subjects to
circumcision or a control group and found a significant reduction
of HPV infection in the circumcision group. At 24 month follow-up,
there was a 27.9% prevalence of high-risk HPV genotypes in the
control group and only a 18.0% prevalence in the circumcision group
(adjusted risk ratio, 0.65; 95% CI, 0.46 to 0.90; P=0.009). Another
recent trial by Auvert et al. in Orange Farm, South
Africa, randomized men to either a circumcision or control group.
At the 21 month visit, the prevalence of high-risk HPV infection
was lower in the circumcised men than the uncircumcised
participants (14.8% and 22.3% respectively, a prevalence rate ratio
of 0.66) in the absence of any difference in reported sexual
behaviour or gonorrhea prevalence.

Two studies have shown that circumcised men report, or were found
to have, a higher prevalence of genital
warts than uncircumcised men; however, a 2009 meta-analysis of
multiple studies found a non-significant association between
genital warts and the presence of a foreskin.

Other sexually transmitted infections

Studies evaluating the effect of circumcision on the incidence of
other sexually transmitted infections have reached conflicting
conclusions. A meta-analysis of
observational data from twenty-six studies found that circumcision
was associated with lower rates of syphilis, chancroid and possibly genital herpes. A large
randomized prospective trial in Uganda found a reduction in HSV-2
infection, but not syphilis infection, in the circumcision arm of
the study. In contrast, some studies have failed to find a
prophylactic benefit to circumcision. A prospective trial in India
found that circumcision offered no protective benefit against
herpes simplex virus type 2, syphilis, or gonorrhea. A clinical study of 5,925 women from
Uganda, Zimbabwe and Thailand found that the circumcision status of
their partner did not significantly affect the incidence of
Chlamydia, gonorrhea or trichomoniasis. Laumann et al.
examined observational data from the United States and found no
significant differences between circumcised and uncircumcised men
in their likelihood of contracting sexually transmitted
diseases.

Hygiene, and infectious and chronic conditions

The American Academy of
Pediatrics (1999) stated: "Circumcision has been suggested as
an effective method of maintaining penile hygiene since the time of
the Egyptian dynasties, but there is little evidence to affirm the
association between circumcision status and optimal penile
hygiene."

An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans
alone is called balanitis. Both conditions
are usually treated with topical antibiotics (metronidazole cream)
and antifungals (clotrimazole cream) or low-potency steroid creams.
Although not as necessary as in the past, circumcision may be
considered for recurrent or resistant cases. Escala and Rickwood
recommend against a policy of routine infant circumcision to avoid
balanitis saying that the condition affects no more than 4% of
boys, does not cause pathological phimosis, and in most cases is
not serious.

Fergusson studied 500 boys and found that by 8 years, the
circumcised children had a rate of 11.1 problems per 100 children,
and the uncircumcised children had a rate of 18.8 per 100. During
infancy, circumcised children were found to have a significantly
higher risk of problems than uncircumcised children, but after
infancy the rate of penile problems was significantly higher among
the uncircumcised. Fergusson et al. said that the great
majority of penile problems were relatively minor (penile
inflammation including balanitis, meatitis, and inflammation of the
prepuce) and most (64%) were resolved after a single medical
consultation. Herzog and Alverez found the overall frequency of
complications (including balanitis, irritation, adhesions,
phimosis, and paraphimosis) to be higher among the uncircumcised
children; again, most of the problems were minor. In a study of 398
randomly selected dermatology students, Fakjian et al.
reported: "Balanitis was diagnosed in 2.3% of circumcised men and
in 12.5% of uncircumcised men." In a study of 225 men, O'Farrell
et al. reported: "Overall, circumcised men were less
likely to be diagnosed with a STI/balanitis (51% and 35%, P
= 0.021) than those non-circumcised." Van Howe found that
circumcised penises required more care in the first 3 months of
life, and that circumcised boys are more likely to develop
balanitis.

The American Medical Association states that circumcision, properly
performed, protects against the development of phimosis. Rickwood
and other authors have argued that many infant circumcisions are
performed unnecessarily for developmental non-retractability of the
prepuce rather than for pathological phimosis. Metcalfe et
al. stated that "Gairdner and Oster made a strong case for
leaving boys uncircumcised, allowing the natural separation of the
foreskin from the glans to take place gradually, and instructing
boys in proper hygiene. This obviates the need for 'preventive'
circumcision." In a study to determine the most cost-effective
treatment for phimosis, Van Howe concluded that using cream was 75%
more cost-effective than circumcision at treating pathological
phimosis.

Urinary tract infections

A meta-analysis of 12 studies (one randomised controlled trial,
four cohort studies and seven
case-control studies)
representing 402,908 children determined that circumcision was
associated with a significantly reduced risk of urinary tract infection (UTI).
However, the authors noted that only 1% of boys with normal urinary
tract function experience a UTI, and the number-needed-to treat
(number of circumcisions necessary) to prevent one urinary tract
infection was calculated to be 111. Because haemorrhage and
infection are the commonest complications of circumcision,
occurring at rate of about 2%, assuming equal utility of benefits
and harms, the authors concluded that the net clinical benefit of
circumcision is only likely in boys at high risk of urinary tract
infection (such as those with high grade vesicoureteral reflux or a history of
recurrent UTIs, where the number needed to treat declined to 11 and
4, respectively).

Some UTI studies have been criticized for not taking into account a
high rate of UTI's among premature infants, who are usually not
circumcised because of their fragile health status. The AMA stated
that “depending on the model employed, approximately 100 to 200
circumcisions would need to be performed to prevent 1 UTI," and
noted one decision analysis model that concluded that circumcision
was not justified as a preventative measure against UTI.

Penile cancer

The American Academy of
Pediatrics (1999) stated that studies suggest that neonatal
circumcision confers some protection from penile cancer, but
circumcision at a later age does not seem to confer the same level
of protection. Further, because penile cancer is a rare disease,
the risk of penile cancer developing in an uncircumcised man,
although increased compared with a circumcised man, remains
low.

The age-adjusted annual incidence of penile cancer is 0.82 per
100,000 in Denmark, 2.9-6.8 per 100,000 in Brazil, 0.9 to 1 per
100,000 in the USA, and 2.0-10.5 per 100,000 in India. Researchers
have reported that the risk of penile cancer is greater in
never-circumcised men than in men who had been circumcised at
birth; estimates of the relative risk include 3 and 22.

Policies of various national medical associations

Australasia

The Royal
Australasian College of Physicians (RACP; 2009) state that
"after extensive review of the literature [they do] not recommend
that routine circumcision in infancy be performed, but [accept]
that parents should be able to make this decision with their
doctors. One reasonable option is for routine circumcision to be
delayed until males are old enough to make an informed choice. In
all cases where parents request a circumcision for their child the
medical attendant is obliged to provide accurate information on the
risks and benefits of the procedure. Up-to-date, unbiased written
material summarising the evidence should be widely available to
parents. In the absence of evidence of substantial harm, parental
choice should be respected."

The Tasmanian President of the Australian Medical Association
(AMA), Haydn Walters, has stated that the AMA would support a call
to ban circumcision for non-medical, non-religious reasons.

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society
posted "Neonatal circumcision revisited" in 1996 and "Circumcision:
Information for Parents" in November 2004. The 1996 position
statement says that "circumcision of newborns should not be
routinely performed","We undertook this literature review to
consider whether the CPS should change its position on routine
neonatal circumcision from that stated in 1982.The
review led us to conclude the following.There is
evidence that circumcision results in an approximately 12-fold
reduction in the incidence of UTI during infancy.The overall incidence of UTI in male infants appears to be
1% to 2%.The incidence rate of the complications of
circumcision reported in published articles varies, but it is
generally in the order of 0.2% to 2%.Most
complications are minor, but occasionally serious complications
occur.There is a need for good epidemiological data
on the incidence of the surgical complications of circumcision, of
the later complications of circumcision and of problems associated
with lack of circumcision.Evaluation of alternative
methods of preventing UTI in infancy is required.More information on the effect of simple hygienic
interventions is needed.Information is required on
the incidence of circumcision that is truly needed in later
childhood.There is evidence that circumcision
results in a reduction in the incidence of penile cancer and of HIV
transmission.However, there is inadequate
information to recommend circumcision as a public health measure to
prevent these diseases.When circumcision is
performed, appropriate attention needs to be paid to pain
relief.The overall evidence of the benefits and
harms of circumcision is so evenly balanced that it does not
support recommending circumcision as a routine procedure for
newborns.There is therefore no indication that the
position taken by the CPS in 1982 should be changed.When parents are making a decision about circumcision, they
should be advised of the present state of medical knowledge about
its benefits and harms.Their decision may
ultimately be based on personal, religious or cultural
factors." and the 2004 information to parents says:
'Circumcision is a "non-therapeutic" procedure, which means it is
not medically necessary. Parents who decide to circumcise their
newborns often do so for religious, social, or cultural reasons.
[...] After reviewing the scientific evidence for and against
circumcision, the CPS does not recommend routine circumcision for
newborn boys. Many paediatricians no longer perform
circumcisions.'

United Kingdom

“Male circumcision that is performed for any reason other than
physical clinical need is termed non-therapeutic (or sometimes
“ritual”) circumcision. Some people ask for non-therapeutic
circumcision for religious reasons, some to incorporate a child
into a community, and some want their sons to be like their
fathers. Circumcision is a defining feature of some faiths.” “The
Association has no policy on these issues.”

The BMA provides that “male circumcision is generally assumed to be
lawful provided that it is performed competently; it is believed to
be in the child’s best interests; and there is valid consent” from
both parents and the child, if possible."

The BMS stipulates that “competent children may decide for
themselves; the wishes that children express must be taken into
account; if parents disagree, non-therapeutic circumcision must not
be carried out without the leave of a court; consent should be
confirmed in writing."

"In the past, circumcision of boys has been considered to be either
medically or socially beneficial or, at least, neutral. The general
perception has been that no significant harm was caused to the
child and therefore with appropriate consent it could be carried
out. The medical benefits previously claimed, however, have not
been convincingly proven, and it is now widely accepted, including
by the BMA, that this surgical procedure has medical and
psychological risks. It is essential that doctors perform male
circumcision only where this is demonstrably in the best interests
of the child. The responsibility to demonstrate that
non-therapeutic circumcision is in a particular child’s best
interests falls to his parents. The BMA considers that the evidence
concerning health benefit from non-therapeutic circumcision is
insufficient for this alone to be a justification for doing
it."

United States

The American Academy of
Pediatrics (1999) stated: "Existing scientific evidence
demonstrates potential medical benefits of newborn male
circumcision; however, these data are not sufficient to recommend
routine neonatal circumcision. In the case of circumcision, in
which there are potential benefits and risks, yet the procedure is
not essential to the child’s current well-being, parents should
determine what is in the best interest of the child." The AAP
recommends that if parents choose to circumcise, analgesia should
be used to reduce pain associated with circumcision. It states that
circumcision should only be performed on newborns who are stable
and healthy.

The American Medical
Association supports the AAP's 1999 circumcision policy
statement with regard to non-therapeutic circumcision, which they
define as the non-religious, non-ritualistic, not medically
necessary, elective circumcision of male newborns. They state that
"policy statements issued by professional societies representing
Australian, Canadian, and American pediatricians do not recommend
routine circumcision of male newborns."

The American
Academy of Family Physicians (2007) recognizes the controversy
surrounding circumcision and recommends that physicians "discuss
the potential harms and benefits of circumcision with all parents
or legal guardians considering this procedure for their newborn
son."

The American Urological
Association (2007) stated that neonatal circumcision has
potential medical benefits and advantages as well as disadvantages
and risks.

Yosef David Weisberg, Rabbi. Otzar Habris.Encyclopedia of the laws and customs of Bris Milah and Pidyon
Haben. Jerusalem: Hamoer, 2002.

Notes and references

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||Some referenced articles are available on-line only in the Circumcision Information and Resource Page’s (CIRP) library or in The Circumcision Reference Library (CIRCS). CIRP articles are chosen from an anti-circumcision point of view, and text in support of this position is often highlighted on-screen using HTML. CIRCS articles are chosen from a pro-circumcision point of view. If documents are not freely available on-line elsewhere, links to articles in one or other of these two websites may be provided.
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